Failure to Provide Physician-Ordered Wound Care for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that physician-ordered wound treatments were provided as prescribed for a resident with a suspected deep tissue injury (SDTI) on the sacrum. The resident, who had multiple diagnoses including dementia, chronic kidney disease, cirrhosis, malignant neoplasm of the breast, urinary incontinence, Alzheimer's disease, anorexia, pressure ulcer of the sacral region, protein calorie malnutrition, and abnormal weight loss, was admitted with a care plan and physician orders specifying cleansing the sacrum, applying zinc barrier cream, and covering with a foam dressing every three days and as needed. Record review showed that the last documented treatment was performed several days prior to the observation, with no as-needed treatments recorded. During incontinence care, it was observed that the resident did not have the required foam dressing in place, nor was it found in the bed or removed during care. Staff interviews confirmed the absence of the dressing, and the DON acknowledged that staff are expected to follow wound treatment orders as written. Facility policy required wound treatments to be provided according to physician orders, including dressing type and frequency.